A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?
Set client-centered, measurable and realistic goals.
Critically analyze client data to determine priorities.
Determine effectiveness of interventions.
Collect and organize client data.
The Correct Answer is D
A. Set client-centered, measurable and realistic goals: This occurs during the planning stage, after data collection and analysis.
B. Critically analyze client data to determine priorities: This step happens after data collection during the diagnosis phase.
C. Determine effectiveness of interventions: This is part of the evaluation stage, which comes after planning and implementation.
D. Collect and organize client data: This is the first step in the nursing process, where the nurse gathers comprehensive information about the client's physical, psychological, sociocultural, developmental, and spiritual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Percussion: Percussion is typically performed before palpation. It helps to detect differences in density of abdominal contents, fluid presence, and gas patterns.
B. Auscultation: Auscultation is performed before any palpation or percussion to prevent altering bowel sounds. It is typically the second step after inspection.
C. Palpation: Palpation is used last during an abdominal assessment to prevent altering the characteristics of bowel sounds and to ensure that any tenderness or abnormal masses are identified after a thorough initial assessment. Palpation can cause changes in bowel sounds and tenderness.
D. Inspection: Inspection is always the first step in any physical examination. It allows for a visual assessment of the abdomen, looking for distension, asymmetry, and skin changes.
Correct Answer is B
Explanation
A. Pincer grasp: The pincer grasp, which involves using the thumb and forefinger to pick up small objects, typically develops around 8 to 12 months of age, not at 4 months.
B. Rolls from tummy to back: At 4 months, many infants start to develop the ability to roll from their tummy to their back. This is a typical milestone for this age and reflects developing motor skills.
C. Walks with support: Walking with support usually begins around 9 to 12 months of age, much later than 4 months.
D. Rolls from back to tummy: Rolling from back to tummy typically occurs a bit later, often around 5 to 6 months. At 4 months, rolling from tummy to back is the more expected milestone.
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